A big misunderstanding is that if you have sinusitis, you need an antibiotic. The problem with sinusitis is often not the infection in the sinuses, it’s the pressure. We have to relieve the pressure. It’s a bone and antibiotics don’t permeate the bone very well. Antibiotics for sinusitis is a highly abused antibiotic script. We have to manage patient expectations.
Why do people get otitis media or sinusitis? Something blocked the back of their nasal pharyngeal airway. It’s almost always allergies, smoking or URI. Almost always. A good clinician will try to figure that out, because if it’s an allergy mediated sinusitis or allergy mediated otitis media, you may alter your therapy and treat them for the allergies.
We need to decrease pressure and we do that by getting the crap out of the sinuses. How? We thin it out by telling the patient to drink lots and lots and lots of fluids, and perhaps saline irrigation. Get the gunk slippery so it comes out. The pressure goes away. You can also vasoconstrict the boggy tissue with decongestants like Sudafed or Afrin nasal spray.
Be very smart about antihistamines because they’re anticholinergic, or drying agents. Someone is sick from sinusitis; they have gook in their sinuses and they’re sneezing a lot. It’s allergy mediated, so you think you should put them on antihistamines. By doing that, you make the gook in their sinuses more concentrated and the patient gets sicker. You cannot use antihistamines on sinusitis when the sinuses are filled. Maybe talk about steroids, but not antihistamines. You can use antihistamines when they’re better.
I’ve scanned peoples’ heads because their headaches were so bad I thought they bled. In reality, it was just really bad sinusitis and someone put them on an antihistamine.
Sinus symptoms are the most common cause of antibiotic overuse. When should we pull the trigger on antibiotics? Those with a fever over 102°F or children can be treated with antibiotics. You can also treat if there’s intense facial pain or prevalent nasal discharge. If someone has over 10 days of symptoms, you can treat it.
A meta-analysis of nine double-blind placebo-controlled trials found no signs or symptoms that really justified treatment, even after seven to 10 days. In a randomized placebo-controlled trial in adults, a 10-day course of amoxicillin compared to a placebo did not reduce symptoms at three days.
What am I saying? Antibiotics are not the way to go with sinusitis.
